Credit Card Authorization Form

Business/Company Name *

Purpose of Payment *

Payment Amount *

By checking this box, I authorize a one-time charge against my credit card for the amount entered above. *

I agree.

Cardholder Information

Credit Card Type *

MasterCard
Visa
Discover Card

Card Number *

Expiration Date (MM/YYYY) *

Security Code *

Usually 3 or 4 digit code located on the back of the card

Cardholder Name *

First

Last

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cardholder's Phone Number *

Checking this box will act as a signature for this form. Please read the following carefully: By signing this document I authorize the City of Marion to charge my credit card for the purpose of payment(s) for business licenses, permits and similar fees. Furthermore, I authorize the City of Marion to verify the information listed above and agree to hold the City of Marion harmless of any dispute with the company issuing the credit card used for this transaction. This authorization is valid for this transaction only. *

I understand and agree to the above.

Name of Person Submitting this form *

First

Last

Date / Time of Submission *

Date

Time

City of Marion, South Carolina

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Credit Card Authorization Form

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City of Marion, SC